EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
1 WORKERS’ COMPENSATION CLAIMS ADMINISTRATION SERVICE AGREEMENT This Service Agreement is effective July 1, 2024 by and between Pacific Secured Equities DBA Intercare Holdings Insurance Services Inc., a California corporation (“IHI”), and the City of South San Francisco, a municipal corporation (“City”).
RECITALS
A. City desires to have specific claims administration and cost containment services performed by IHI in accordance with applicable laws and regulations in connection with City’s Workers’ Compensation Program.
B. IHI has developed and manages certain health care management products and services including claims administration, telephonic case management, utilization review and bill review.
C. IHI is willing to provide such services on the terms and conditions hereinafter stated.
NOW THEREFORE, in consideration of the mutual covenants, agreements, representations, and warranties contained in this Agreement, the parties agree as follows:
AGREEMENT
1. Terms. This Service Agreement shall be for the period set forth below except as may be amended or canceled as hereinafter provided.
1.1. This Agreement is effective July 1, 2024 and shall continue to be in force for three years through June 30, 2027 (the “Initial Term”). City may, upon sixty (60) days prior written notice, in its sole and absolute discretion, extend the end date of this Agreement for up to two successive twelve month periods thereafter (each a “Renewal Term.”) Any such extension shall require a written amendment to this Agreement, as provided for herein.
1.2. Notwithstanding the foregoing, in the event CITY requests in writing that INTERCARE continue to provide any services for claims reported hereunder after the expiration or cancellation hereof, this Agreement shall remain in effect to govern the parties’ respective rights and obligations with respect to the services for claims reported.
2. Definitions. In addition to the various terms defined in the body of this Agreement, the following capitalized terms shall have the meanings given below:
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
2 2.1. “Agreement” means this document and any amendments or schedules attached hereto from time to time including, without limitation, any amendments or schedules for terms and conditions that may have been renewed.
2.2. “Allocated Loss Expenses” shall mean, in addition to fees to be paid in accordance with items listed or inferred herein Agreement, all reasonable expenses necessary to the adjustment of a claim in accordance with this Agreement, including but not limited to all costs, charges, or expenses of third parties incurred by IHI, its agents, employees or officers that are incurred in connection with or related to a Claim including, without limitation, the following:
2.2.1 court costs, fees and expenses of attorneys, court reporters, investigators (including, without limitation, undercover operatives and detective services), experts and witnesses, and fees for obtaining diagrams, reports, documents, and photographs;
2.2.2 pre and post-judgment interest paid as a result of litigation;
2.2.3 fees for service of process;
2.2.4 costs of legal transcripts of testimony taken at coroners’ inquests or from criminal or civil proceedings;
2.2.5 costs of copies of any public records and/or medical records;
2.2.6 costs of independent medical examinations and/or evaluations for rehabilitation and/or to determine the extent of the Claimant’s and/or the City’s liability;
2.2.7 costs of independent field examiners and related expenses to investigate a claim;
2.2.8 costs of all Cost Containment Services (defined on Exhibit A Service Scope of Work) including but not limited to: medical bill review or adjudication including network related expenses and independent bill review fees; medical management expenses related to medical cost containment efforts including, without limitation, utilization review provided by clinical staff including peer review including fees associated with the request for Independent Medical Review; nurse case management including telephonic or field case management; a. Prior authorization is an arrangement written into the UR plan that describes the specific conditions or circumstances under which a treating physician will be assured of appropriate reimbursement for specific treatment, without submitting an RFA before, during or after the treatment. As long as that treatment fits the description of prior
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
3 authorization in the UR plan, the treating physician may treat and then submit the bill for payment.
b. A Request for Authorization (RFA) is a form that a medical provider is required to use to request treatment, diagnostic tests or other medical services for an injured worker. If the treatment request was first made verbally, it must be confirmed in writing. The treating physician must fill out the form and attach the doctor's first report of occupational injury or illness (form 5021), the primary treating physician progress report (DWC form PR-2), or a narrative report that contains the same information required in the primary treating physician progress report form. As used in this Agreement, an RFA is defined as a request from a healthcare professional either through the RFA Form or as contained in a single medical report. An RFA may have multiple treatment modality.
Some treatment modality may be authorized by a non-clinician such as the Adjuster and others may be referred to a Utilization Review Organization (“URO”) depending on the City's Protocol and Utilization Review Guidelines and in such instances when the treatment plan may need to be delayed, modified or denied.
c. A Peer Advisor is a Licensed Healthcare Professional who is in the same licensing category (MD, DO, DC) as the provider requesting authorization for the treatment, who is trained in occupational medicine and can examine treatment plans and provide objective and unbiased determinations on the necessity of the treatment plan.
d. A Specialty Review is a utilization review conducted by a Peer Reviewer licensed in the same field of specialization as the healthcare professional requesting the authorization for treatment. The distinction here is that the area of specialization of the Peer Advisor conducting the review must match the specialty of the healthcare professional requesting the treatment.
2.2.9 any other similar costs, fees or expenses reasonably chargeable to the investigation, negotiation, settlement or defense of a Claim or loss or to the protection of the subrogation rights of City;
2.2.10 costs of interpreters;
2.2.11 costs of credit bureau and index reports;
2.2.12 costs related to the special investigation of fraudulent claims; and
2.2.13 safety and loss control services.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
4 2.3. “Claim” means a request made by City for the receipt of benefits under the Insurance Program.
2.4. “Claim File” means the administrative record of a Claim, including, without limitation, the accounting of expenses related to a Claim.
2.5. “Claimant” means any employee insured by City and entitled to coverage under the Insurance Program.
2.6. “Qualified Claim” means a Claim entitled to receive benefits under the Insurance Program.
2.7. “Indemnity Claim” means a Qualified Claim including, without limitation, one or more of the following elements:
2.7.1 the injured employee's time off work due to a compensable or potentially compensable injury meets the applicable jurisdictional waiting period;
2.7.2 coverage issues;
2.7.3 issues of compensability;
2.7.4 requires subrogation investigation;
2.7.5 modified duty is provided for more than 12 weeks, or which has or may result in any of the following benefits:
a. Temporary disability or salary in lieu thereof
b. Permanent Disability
c. Life Pension
d. Death Benefits
e. Vocational Rehabilitation
f. Supplemental Job Displacement Voucher Benefits
2.7.6 results in an award of either permanent partial or permanent total disability benefits regardless of whether the jurisdictional waiting period is met or not; and
2.7.7 results in a Petition for Adjudication of Claim being filed before the applicable state agency even if no benefits are awarded.
2.8. “Future Medical Claim” means a Qualified Claim including, without limitation, one or more of the following elements:
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
5 2.8.1 An Indemnity claim which has been concluded and resulted in an award of permanent partial or permanent total disability benefits along with a provision for “future medical treatment” provided the permanent partial or permanent total disability award has been satisfied and no ongoing indemnity payments is being paid;
2.8.2 An Indemnity claim, which has been resolved and is open only for purposes of administering the future medical provision of the award, provided the medical payment activity does not exceed three times per year.
2.9. “Medical Only Claim” means a Qualified Claim including, without limitation, one or more of the following elements:
2.9.1 a work-injury case that does not result in compensable lost time but results in medical treatment beyond first aid.
2.9.2 any workers' compensation claim where the only issue is payment of medical bills for reasonable and necessary care or treatment;
2.9.3 the total amount paid on the claim for medical care or treatment is $3,000 or less;
2.9.4 no investigation is needed to determine compensability of the claim.
2.9.5 time off work due to a potentially compensable injury does not meet the jurisdictional waiting period;
2.9.6 there is no exposure for permanent partial or permanent total disability benefits; and
2.9.7 where modified duty is provided for no longer than 12 weeks
2.9.8 Indemnity benefits are not due or potentially due
2.9.9 Conversion Rule – claim may be converted to indemnity if one or more of the following:
a. Total cost of medical care exceeds $3,500 and is not ready for immediate closure when the dollar amount pierces the threshold; b. claim has been opened for 180 days or more; and
c. additional investigation is needed to determine
compensability of claim even if injured worker is not losing time or additional investigation is needed to determine subrogation status.
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Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
6 2.10. “Asbestos Claim” means a Qualified Claim including, without limitation, any Workers’ Compensation claim resulting from a disease or illness caused by continuous exposure to some deleterious substance, microorganism or harmful substances in the course of employment provided City is not the leading defendant.
2.11. “First Aid” means “any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, and so forth, which do not ordinarily require medical care. Such one-time treatment and follow-up visit for the purpose of observation is considered first aid even though provided by a physician or registered professional personnel.” Insured employer in California are required to report all claims for which medical treatment costs are incurred including first aid claims. First aid claims are created as a medical only claim and reported to the carrier along with the associated costs. The carrier is responsible for reporting these claims to WCIRB.
2.12. “Incident Only” means a claim for which an incident is reported with no medical attention or if medical attention is provided, it is administered immediately after the injury occurs and at the location where it occurred with no associated medical cost.
2.13. “Services” means a collective reference to the products and/or services set forth in this Agreement to be provided by IHI.
2.14. “Service Fees” means a collective reference to the various fees to be paid by City to IHI pursuant to this Agreement.
2.15. “Solvent” means, when used with respect to either party, that (a) such party is not “insolvent” within the meaning of 11 U.S.C. Section 101(32) and the cases interpreting the same; (b) such party is generally able to pay its debts as they become due; and (c) such party does not have unreasonably small capital to carry on such party’s business as theretofore operated and all businesses in which such party is about to engage.
2.16. “Insurance Program” means the insurance program established by City to provide workers’ compensation benefits to employees of City’s employer members as set forth under the rules, ordinances and provisions of City.
3. Services To Be Performed by IHI. IHI agrees to perform, and shall provide, each of the following Services on the terms set forth herein and in Exhibit A Scope of Work attached hereto:
3.1. Claims Administration Services. IHI shall:
3.1.1 review each Claim received from City and process each such Claim in accordance with the Insurance Program’s statement of work;
3.1.2 conduct an investigation of each reported Claim to determine on behalf of City for each reported employee injury or illness those benefits, if any,
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
7 that should be rendered under the Insurance Program. Any Claim believed to be fraudulent shall be referred to IHI’s in-house special investigative unit for further investigation, and the unit shall with the prior approval of City determine whether such Claim is required to be submitted to the applicable District Attorney’s Office or United States Attorney;
3.1.3 establish and maintain an electronic record file for each Claim;
3.1.4 maintain an average Caseload of 150 cases or less per Indemnity Adjuster. The average Indemnity caseload shall not exceed 150 cases in any given quarter. In the event that the frequency of new claims increases to a level that warrants the addition of staff to maintain the caseload requirements, IHI and City shall agree to evaluate the caseload for a period of at least three consecutive months before adjusting the number of staff accordingly. Caseload shall be defined by the number of indemnity and future medical cases open on the last day of each calendar month.
3.1.5 arrange for and retain independent investigators or medical or other experts, to the extent deemed necessary or desirable by IHI, in connection with processing any Claim;
3.1.6 maintain an estimate of the total costs of all reasonable and foreseeable benefits payable and related expenses on each Qualified Claim based upon the facts and circumstances known at the time and update the same on regular and periodic basis;
3.1.7 pay medical and death benefits, temporary and permanent disability compensation and other losses and expenses on Qualified Claims (a) if, in the judgment of IHI, such payment would be prudent for City and (b) pursuant to the terms of this Agreement or as may be approved by City in its sole and absolute discretion;
3.1.8 perform reasonable and necessary administrative and clerical work in connection with Claims including the preparation of checks drawn on the account or accounts established by, or at the direction of, City;
3.1.9 assist in connection with City’s selection of defense counsel to defend Qualified Claims or losses, if requested by City;
3.1.10 assist City’s selected defense counsel in preparing the defense of litigated Claims, negotiating settlements, and pursuing subrogation or contribution actions;
3.1.11 (a) oversee the treatment programs recommended for Claimants by physicians, medical specialists, and other health care providers by reviewing all reports prepared by such providers and maintaining such contact with such
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Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
8 providers as may be appropriate in the judgment of IHI; and (b) manage the medical treatment in accordance with Insurance Program;
3.1.12 prepare and file on behalf of City all forms related to the processing of Claims that are required by the Insurance Program or government agencies except for MMSEA filings which shall remain the responsibility of the City;
3.1.13 provide City with standard computerized reports, including, but not limited to, monthly loss run and payment registers, and statistical reports; if additional reports, special reports, conversion or special programming or information is needed, the cost payable by City for such additional items will be limited to costs actually incurred by IHI to prepare such items; City may specify from the list of available reports which reports will be sent to them on a regular basis;
3.1.14 provide initial claims forms packets as deemed appropriate by IHI for efficient administration of Claims in compliance with the Insurance Program; and
3.1.15 comply with City’s service instruction guidelines for the administration of the Services as such Services are set forth in this Agreement.
3.2. Medical Expense Control and Managed Care. IHI shall provide information to ill or injured Claimants regarding the benefits available under the Insurance Program and counsel any Claimants who wish to obtain the assistance of third parties for workrelated illnesses or injuries.
3.3. Claims Counseling. IHI shall:
3.3.1 consult with key personnel of City on the establishment and coordination of necessary procedures and practices to meet any needs of City with respect to the administration and processing of Claims;
3.3.2 participate in the orientation of City’s personnel who are directly or indirectly involved in the processing of Claims;
3.3.3 provide information on changes or proposed changes in legislation, rules or regulations affecting the responsibility of City with respect to Claims; and
3.3.4 review the development of the Insurance Program periodically with representatives of City in order to identify problems and recommend corrective action.
3.3.5 provide training sessions annually to the City including Basic Workers’ Compensation Guidelines and Fraud Detection.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
9 3.4. Medical Control Services. IHI shall:
3.4.1 assist City, where permitted, in the selection of (a) a medical provider network and panel of physicians or other health care providers to initially treat Claimants and (b) a medical provider network and panel of medical specialists to provide long-term or specialty care;
3.4.2 where appropriate, assist City with the interpretation of medical reports to consider the circumstances under which an ill or injured Claimant, who desires to do so, could return to work in the shortest period of time;
3.4.3 endeavor to utilize telephonic medical case management services when warranted using IHI’s Managed Care Division, InterMed ; and
3.4.4 adjudicate medical/provider billings in accordance with a fee schedule comparable to the Official Medical Fee Schedule or City’s direct contract(s) with provider(s) using InterMed.
3.5. Medical Management Services. IHI, through its Managed Care Division, InterMed Cost Containment services, shall provide:
3.5.1 new Claim intake and triage services;
3.5.2 PPO network direction and negotiation;
3.5.3 utilization review;
3.5.4 surgical pre-certification;
3.5.5 disability management; and
3.5.6 telemedicine program if applicable.
3.6. Bill Review Services. IHI, through its Managed Care Division, InterMed Cost Containment services, shall:
3.6.1 provide line-by-line audit of all codes being billed; auto adjudication; outpatient audits, including all ambulatory surgical services; inpatient fee schedule audits and reviews; medical/legal bills and ancillary services that may need to be reported to a regulatory agency such as invoices for translation and interpreting services, copy service and other services required by regulatory agencies; and
3.6.2 comply with Statutory regulation by integrating data feeds from the bill review application and claims management system into the applicable jurisdiction’s electronic data interface (EDI) feed to comply with the EDI mandate for medical bill/payments.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
10 3.7. Medicare, Medicaid and State Children’s Health Insurance Program Extension Act of 2007 (MMSEA) Section 111 Mandatory Reporting.
3.7.1 To assist City in fulfilling its mandatory Medicare beneficiary reporting obligations under the MMSEA Section 111 as set forth in 42 USC 139(b)(7)&(8) and the Center for Medicare Services (CMS) User Guide published March 16, 2009 and as amended and revised periodically by CMS, IHI will perform the following reporting services:
a. IHI will establish an electronic interface with CMS to capture and report data in the format prescribed by the CMS User Guide Specifications.
b. IHI will report directly to CMS on behalf of City as an Account Designee (reporting agent), as such term is defined in the CMS User Guide as amended from time to time by CMS.
c. City will be considered a Responsible Reporting Entity (RRE) as that term is defined in the CMS User Guide. City will be responsible for maintaining a valid RRE Identification Number as described in the CMS User Guide and is a condition precedent to IHI performing the duties under this section. Failure to maintain the RRE Identification Number will result in IHI’s inability to properly report claims on behalf of City. IHI assumes no responsibility for maintaining a valid RRE Identification Number on behalf of City.
3.7.2 IHI will further assist City by collecting the legal name, social security number, gender, date of birth of the Medicare Beneficiary; prepare required data files and submit to CMS a monthly eligibility query and submit a quarterly report with the appropriate claims as defined in the CMS User Guide on the RRE’s designated reporting group.
3.7.3 IHI will be responsible for fines assessed to City in connection with the MMSEA beneficiary reporting requirement that relate to IHI’s negligent acts or omissions except to the extent that:
a. Such fines and penalties are the direct result of specific direction given by City and/or its agent or the actions or omissions of City and/or its agent; or
b. IHI did not receive information or received incorrect information from City that is essential to the performance of the duties set forth herein in a timely manner so as to be able to comply with the terms of this Agreement.
3.7.4 Provide evidence of Quarterly report submitted to CMS on behalf of CITY.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
11 3.8. Additional Services. IHI shall periodically meet with City and IHI shall agree to provide such additional claim administration services as may be required from time to time for such additional Service Fees as may be agreed upon.
3.9. IHI shall be available to discuss the Program with CITY monthly and to provide standard loss reports at each of these meetings as may be reasonably requested.
4. City Obligations to IHI. City agrees to undertake and perform all of the following tasks:
4.1. City shall pay Intercare the fees and related expenses as provided herein per the terms of Exhibit B Fee Schedule attached hereto and incorporated herein.
4.2. encourage all employees to promptly report all relevant injuries or illnesses in writing to IHI;
4.3. promptly forward the form Employer’s Report of Injury or Illness or similar document, all letters, correspondence, or any other information, whether oral or written, received by City which is or could be relevant to the efficient and proper handling of any Claim;
4.4. fully cooperate with IHI in the performance of this Agreement;
4.5. provide IHI with any necessary data within City’s possession or control to enable IHI to perform under this Agreement; and
4.6. establish a zero-balance account to pay claim related expenses in a timely manner.
4.7. City shall participate in IHI’s Prescription Management Benefit program, or contract directly with another prescription benefit management service. If contracting directly with another service, such provider shall be capable of providing electronic data which is compatible with IHI’s electronic claims record system. Client shall bear the cost of system integration and the bill review fee will be applied to all prescription bills.
4.7.1 If City is participating in IHI’s PBM program, prescription bills for participating pharmacies shall not be subject to a bill review fee provided the PBM Network is Intercare’s preferred vendor in which case the CITY shall receive the network discount for the drug cost and allowable dispensing allowance.
4.7.2 IHI shall endeavor to convert out of network prescription bills by referring non-participating pharmacies to the PBM Network.
5. Discretionary Disbursement Authority Limit of IHI.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
12 5.1. Disbursements. The aggregate limit on any discretionary payment by IHI for a Claim together with the individual Allocated Loss Expenses shall be $5,000. City may increase this amount at any time upon giving prior written notice to IHI. It is agreed that IHI shall have full financial authority and control in all matters pertaining to the payment, processing, investigation and administration of Claims within the limits established by this Section.
5.2. Settlement Authority. IHI shall request authorization from City prior to any settlement.
5.3. IHI Funds. It is expressly understood that IHI shall not be required to (a) advance IHI’s own funds to pay Claims or Allocated Loss Adjustment Expenses for any Qualified Claim hereunder or (b) perform any Services hereunder if City fails to provide adequate funds or funds in a timely manner as herein set forth or if funds previously provided by or on behalf of City are seized, frozen or otherwise unavailable to IHI to allow required payments to be made timely on account of the bankruptcy or receivership or other insolvency proceeding of City or Insurer, in cases where Insurer funds claim account, IHI will have no obligation to perform any claim services or payments during any period of underfunding.
6. Termination and Cancellation
6.1. Termination.
6.1.1 Breach. If IHI or City fails to comply with or perform when due any term or condition of this Agreement, the other party shall notify the defaulting party of its default in writing, and the defaulting party shall have ninety days to cure the default; provided, however, notwithstanding the foregoing, City shall be required to cure any default relating to the payment of Service Fees within thirty days of its due date. If the default is not so cured to a reasonable degree, the nondefaulting party may declare, in writing and without further notice, that this Agreement is terminated. Additionally, this Agreement shall terminate immediately, upon written notice of either party to the other party, in the event of the passage of a law or promulgation of a regulation or an action or investigation by any regulatory body which would (a) materially and adversely affect such party’s rights and obligations hereunder or (b) prohibit the relationship between the parties or the operations of the parties hereunder.
6.1.2 Without Cause. City and IHI will have the right to terminate this Agreement without cause by giving ninety (90) days prior written notice to the other party of its intention to terminate pursuant to this provision, specifying the date of termination. City will pay to IHI the compensation earned for work or services performed and not previously paid for through the date of closing.
6.1.3 No Effect. Termination of this Agreement shall have no effect on the rights and obligations of the parties arising out of any transaction occurring on
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Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
13 or prior to the date of such termination. City shall continue to fulfill its obligations to IHI under this Agreement that is pending on the date of termination. And IHI shall continue to fulfill its obligations to City under this Agreement that are pending on the date of termination.
6.1.4 Bankruptcy. Either party may terminate this Agreement immediately upon written notice to the other party in the event that (a) the other party files a petition for reorganization under the provisions of federal bankruptcy laws or similar laws of another jurisdiction, (b) a receiver of all or substantially all of the property of the other party is appointed and not removed within thirty days, (c) the other party’s business is no longer Solvent or (d) the other party is convicted of fraud, embezzlement or other
6.1.5 Options on Termination. Once Services are commenced by IHI hereunder for a Claim, they shall continue until the Claim is finally closed or until this Agreement expires, cancels or terminates, whichever occurs first. In the event of any expiration, cancellation or termination of this Agreement, IHI will, upon request from City and at City’s expense, promptly transfer all pending and closed Claims to either City or another administrator.
6.1.6 Termination Transfer Policy.
a. Post-Termination Processing of Claims. If requested by City, IHI shall continue to process any qualified claims or losses remaining open at the termination plus any other claims received with occurrence dates that fall within the period or periods of this Agreement provided that the City shall continue to make adequate funds available for the payment of such qualified claims or losses and any allocated loss expenses. The additional administrative fee(s) for this service shall be negotiated and agreed to prior to the effective date of termination.
b. Post-Termination File Maintenance/Disposal. Upon
cancellation of this Agreement, IHI shall deliver, at City’s sole cost, the files IHI has maintained for qualified claims or losses except those IHI will continue to process (but not including any computer hardware, firmware, software or proprietary information of IHI); provided, however, as follows:
(i) Claims Data. Upon request of City, IHI shall
additionally provide file information using computer disks, flash drives, or secure file transfer protocol (SFTP). All data transfer will be encrypted using shared keys. The selection of usage of computer disks, flash drives, or SFTP shall be at the discretion of IHI. Such disks, flash drives, or SFTP transfer shall be produced at the sole expense of the City.
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Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
14 (ii) Continued Inspections. IHI or its agents, employees or attorneys shall continue to be entitled to inspect such files and make copies or extracts there from.
(iii) Option to Retain or Destroy. IHI shall give City thirty (30) days prior written notice of its intent to transfer files to City. If Client does not agree to accept these files within such period, the files will be retained for an additional ninety (90) days or destroyed at IHI option. The Client shall have no recourse against IHI for failure to retain or the destruction of the files. The City agrees to accept such transfers of files unless City notifies IHI in writing that such files do not need to be retained in accordance with the City’s records retention schedule, and IHI may destroy such files. (iv) City Records. On termination of this Agreement, IHI shall promptly surrender to the City all records that in any way pertain to the business of the City or to any of its members, including claims, files, invoices, manuals, and other written, printed, or computer-stored information pertaining to the City. It is agreed that the City owns all records that in any way pertain to the business of the City. City shall be responsible for all cost related to the transfer of records.
7. Practice of Law and Professional Advice. It is understood and agreed that IHI shall not perform, and City will not request performance of any services by IHI that may constitute the unauthorized practice of law. Services provided shall not be considered legal, tax or accounting advice, and IHI shall in no event give, or be required to give, any legal opinion or provide any legal, tax or accounting representation to City. City acknowledges that IHI has been engaged to provide certain professional services and that it is not the intent of the parties that IHI assume any insurance risk. IHI shall not act as an insurer for City; and this Agreement shall not be construed as an insurance policy; it being understood that IHI is in no event financially responsible for payment or satisfaction of City’s claims, lawsuits, or any form of cause of action against City from IHI funds.
8. Indemnification.
8.1 Each party shall indemnify, defend and hold the other party harmless from and against all claims, demands, actions, causes of action, liabilities, losses, damages, fines, fees, assessments, arbitrations, investigations, settlements, lawsuits or other proceedings, any and all appeals therefrom and the costs and expenses incurred in connection therewith, including attorney’s fees, arising from or related to the sole negligence, error or omission, gross negligence or willful misconduct of the party under this Agreement.
8.2. Notice to Indemnifying Party. If a party (the “Indemnitee”) receives written notice of any claim or the commencement of any action or proceeding with
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Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
15 respect to which another party (the “Indemnifying Party”) is obligated to provide.
Indemnitee shall (a) provide the Indemnifying Party written notice thereof, (b) tender control of the defense of the indemnified claim to the Indemnifying Party and once tender of control of the defense occurs, the indemnifying party shall make no settlement, compromise or otherwise resolve the claim in any manner which would injure in any way, the Indemnitee, and (c) not settle or otherwise resolve the indemnified claim without the prior written consent of the Indemnifying Party. In any event, the Indemnitee and the Indemnifying Party shall cooperate in the compromise of, or defense against, any such claim.
8.3. Determination of Defense and Indemnity Obligations. The City and IHI agree that a determination of the defense and indemnity obligations as set forth in this Provision shall be based upon the following:
8.3.1 If the conduct complained of involves any alleged act, error or omission, including any intentional tort, willful misconduct, negligence or gross negligence by City or its affiliated companies, or its directors, officers, or employees, under the terms of this Service Agreement, including any allegations, demands, actions, damage, loss, costs and/or expenses whatsoever, as specified above, under this Service Agreement CITY shall defend and indemnify Intercare as set forth above. In such event, CITY shall have the right to select, with the prior consent of Intercare, such consent not to be unreasonable withheld, the attorneys to conduct the defense and City and such attorneys shall have the right to direct the conduct of said defense.
8.3.2 If the conduct complained of involves any alleged act, error, or omission, including any intentional tort, willful misconduct, negligence or gross negligence by Intercare or its directors, officers, or employees, arising out of or in any way related to Intercare’s obligations under the terms of this Service Agreement, other than any action taken by Intercare for or at the specific direction of City, including any allegations, demands, actions, damage, loss, costs and/or expenses whatsoever, as specified above, under this Agreement, Intercare shall defend and indemnify City as set forth above. In such event Intercare shall have the right to select, with the prior consent of City, such consent not to be unreasonably withheld, the attorneys to conduct the defense and Intercare and such attorneys shall have the right to direct the conduct of such defense.
8.3.3 If the alleged wrongful conduct cannot be determined from the allegations as pleaded, each party shall defend itself until the conduct complained of is clarified during the course of the litigation, at which time the defense and indemnity obligation shall promptly be determined in accordance with the terms of this provision; provided, however, in the event it is determined that one party is obligated to indemnify the other party, the party shall promptly reimburse other party for any fair and reasonable fees and expenses incurred by the other party up to the time of such determination.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
16 9. IHI Claim Administration Standards.
9.1. Claim Files. All Claim Files and related correspondence and documents shall be digitized and maintained in an electronic format and shall be available for review by City during business hours.
9.1.1 Once the records are digitized and attached to the electronic claim file, IHI shall destroy the hard copy version of the record within 30 days of verifying the digitized version has been committed to the soft copy file.
9.1.2 Records retained in electronic or digital form shall be retained for the duration of the contract and transferred to the City or City’s Designee within 30 days from contract termination.
9.1.3 A closed claim transferred in a hard copy format to IHI shall be stored for 7 years from the last provision of benefits. All files designated as “Future Medical” claims shall not be destroyed unless all related file content and documents are digitally converted to a soft copy file.
9.1.4 IHI shall notify City and provide a list of hard copy claims that meet record the record destruction policy. City shall have the right to have the such files stored and maintained or digitized at City’s own cost.
9.2. Diary System. IHI shall utilize a computer-generated diary system to provide ongoing file maintenance and facilitate review.
9.3. Service Instruction Guidelines. IHI and CITY shall develop and maintain a Service Instruction Guideline to supplement the contract as a working document outlining the ongoing service instructions to be followed by IHI and the claims team.
9.4. Prompt Payments. City agrees to report all Claims to IHI within five days of City’s knowledge of such Claim. IHI agrees to make every reasonable commercial effort to disburse disability payments within fourteen days of the date on which IHI receives a report indicating that disability payments are due.
9.5. Reserve Analysis. IHI agrees to complete a reserve analysis worksheet for each Indemnity Claim when initially reported. Full reviews may also be performed whenever additional material information is received by IHI. IHI’s current policy is to reserve sufficient sums to cover all probable expenditures and in accordance with Self Insured Plans Guidelines with respect to a Claim.
9.6. Investigation. IHI agrees that all compensability investigations will be performed and completed within ninety days of IHI’s knowledge of the questionable Claim.
9.7. Permits/Licenses. IHI agrees to obtain and maintain all material permits and licenses as required by law for the performance of the Services.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
17 9.8. Contact. IHI shall endeavor to complete three-point contacts (physician, employer, and employee) by telephone or mail within two business days of receipt of a Claim.
10. Insurance. IHI shall maintain the following minimum insurance coverages during the term of this Agreement:
10.1. Workers’ compensation. Workers’ Compensation. IHI shall, at its sole cost and expense, maintain Statutory Workers’ Compensation Insurance and Employer’s Liability Insurance for any and all persons employed directly or indirectly by IHI. The Statutory Workers’ Compensation Insurance and Employer’s Liability Insurance shall be provided with limits of not less than ONE MILLION DOLLARS ($1,000,000) per accident.
10.2. Commercial General and Automobile Liability Insurance.
10.2.1 IHI at its own cost and expense, shall maintain commercial general and automobile liability insurance for the term of this Agreement in an amount not less than ONE MILLION DOLLARS ($1,000,000.00) per occurrence, combined single limit coverage for risks associated with the work contemplated by this Agreement. If a Commercial General Liability Insurance or an Automobile Liability form or other form with a general aggregate limit is used, either the general aggregate limit shall apply separately to the work to be performed under this Agreement or the general aggregate limit shall be at least twice the required occurrence limit. Such coverage shall include but shall not be limited to, protection against claims arising from bodily and personal injury, including death resulting there from, and damage to property resulting from activities contemplated under this Agreement, including the use of owned and non-owned automobiles.
10.2.2 Minimum scope of coverage. Commercial general coverage shall be at least as broad as Insurance Services Office Commercial General Liability occurrence form CG 0001 or GL 0002 (most recent editions) covering comprehensive General Liability and Insurance Services Office form number GL 0404 covering Broad Form Comprehensive General Liability. Automobile coverage shall be at least as broad as Insurance Services Office Automobile Liability form CA 0001 (ed. 12/90) Code 8 and 9. No endorsement shall be attached limiting the coverage.
10.2.3 Additional requirements. Each of the following shall be included in the insurance coverage or added as a certified endorsement to the policy:
a. The insurance shall cover on an occurrence or an accident basis, and not on a claims-made basis.
b. Any failure of IHI to comply with reporting provisions of the policy shall not affect coverage provided to City and its officers, employees, agents, and volunteers.
10.3 Professional Liability Insurance.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
18 10.3.1 General requirements. IHI, at its own cost and expense, shall maintain for the period covered by this Agreement professional liability insurance for licensed professionals performing work pursuant to this Agreement in an amount not less than ONE MILLION DOLLARS ($1,000,000) covering the licensed professionals’ errors and omissions. Any deductible or self-insured retention shall not exceed ONE HUNDRED FIFTY THOUSAND DOLLARS $150,000 per claim.
10.3.2 Claims-made limitations. The following provisions shall apply if the professional liability coverage is written on a claims-made form:
a. The retroactive date of the policy must be shown and must be before the date of the Agreement.
b. Insurance must be maintained and evidence of insurance must be provided for at least five (5) years after completion of the Agreement or the work, so long as commercially available at reasonable rates. c. If coverage is canceled or not renewed and it is not replaced with another claims-made policy form with a retroactive date that precedes the date of this Agreement, IHI must provide extended reporting coverage for a minimum of five (5) years after completion of the Agreement or the work.
The City shall have the right to exercise, at the IHI’s sole cost and expense, any extended reporting provisions of the policy, if the IHI cancels or does not renew the coverage.
d. A copy of the claim reporting requirements must be submitted to the City prior to the commencement of any work under this Agreement.
10.4 All Policies Requirements.
10.4.1 Acceptability of insurers. All insurance required by this section is to be placed with insurers with a Bests' rating of no less than A:VII.
10.4.2 Verification of coverage. Prior to beginning any work under this Agreement, IHI shall furnish City with complete copies of all policies delivered to IHI by the insurer, including complete copies of all endorsements attached to those policies.
All copies of policies and certified endorsements shall show the signature of a person authorized by that insurer to bind coverage on its behalf. If the City does not receive the required insurance documents prior to the IHI beginning work, it shall not waive the IHI’s obligation to provide them. The City reserves the right to require complete copies of all required insurance policies at any time.
10.4.3 Notice of Reduction in or Cancellation of Coverage. A certified endorsement shall be attached to all insurance obtained pursuant to this Agreement stating that coverage shall not be suspended, voided, canceled by either party, or reduced in coverage or in limits, except after thirty (30) days' prior written notice by certified mail, return receipt requested, has been given to the City. In the event that any coverage required by this section is reduced, limited, cancelled, or
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
19 materially affected in any other manner, IHI shall provide written notice to City at IHI’s earliest possible opportunity and in no case later than ten (10) working days after IHI is notified of the change in coverage.
10.4.4 Additional insured; primary insurance. City and its officers, employees, agents, and volunteers shall be covered as additional insureds with respect to each of the following: liability arising out of activities performed by or on behalf of IHI, including the insured’s general supervision of IHI; products and completed operations of IHI, as applicable; premises owned, occupied, or used by IHI; and automobiles owned, leased, or used by the IHI in the course of providing services pursuant to this Agreement. The coverage shall contain no special limitations on the scope of protection afforded to City or its officers, employees, agents, or volunteers.
A certified endorsement must be attached to all policies stating that coverage is primary insurance with respect to the City and its officers, officials, employees and volunteers, and that no insurance or self-insurance maintained by the City shall be called upon to contribute to a loss under the coverage.
10.4.5 Deductibles and Self-Insured Retentions. IHI shall disclose to and obtain the approval of City for the self-insured retentions and deductibles before beginning any of the services or work called for by any term of this Agreement. Further, if the IHI’s insurance policy includes a self-insured retention that must be paid by a named insured as a precondition of the insurer’s liability, or which has the effect of providing that payments of the self-insured retention by others, including additional insureds or insurers do not serve to satisfy the self-insured retention, such provisions must be modified by special endorsement so as to not apply to the additional insured coverage required by this agreement so as to not prevent any of the parties to this agreement from satisfying or paying the self-insured retention required to be paid as a precondition to the insurer’s liability.
Additionally, the certificates of insurance must note whether the policy does or does not include any self-insured retention and also must disclose the deductible.
During the period covered by this Agreement, only upon the prior express written authorization of Contract Administrator, IHI may increase such deductibles or self-insured retentions with respect to City, its officers, employees, agents, and volunteers. The Contract Administrator may condition approval of an increase in deductible or self-insured retention levels with a requirement that IHI procure a bond, guaranteeing payment of losses and related investigations, claim administration, and defense expenses that is satisfactory in all respects to each of them.
10.4.6 Subcontractors. IHI shall include all subcontractors as insureds under its policies or shall furnish separate certificates and certified endorsements for each subcontractor. All coverages for subcontractors shall be subject to all of the requirements stated herein.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
20 10.4.7 Wasting Policy. No insurance policy required by Section 4 shall include a “wasting” policy limit.
10.4.8 Variation. The City may approve a variation in the foregoing insurance requirements, upon a determination that the coverage, scope, limits, and forms of such insurance are either not commercially available, or that the City’s interests are otherwise fully protected.
11. Waiver of Requirement to Exhaust Court Remedies. City hereby expressly waives application of the doctrines of exhaustion of remedies, abstention, or comity and all other rights that might otherwise require that claims against City, to the extent related to or arising hereunder, be heard in any court or other forum.
12. Agreement to Arbitration. The parties hereto agree that any dispute or claim that is directly or indirectly related to the Agreement, whether arising as a matter of tort, contract or otherwise, shall be resolved by binding arbitration under the commercial arbitration rules of the American Arbitration Association (“AAA”). An arbitration proceeding may be commenced only upon the filing with the AAA of a Statement of Claim (within the meaning of the AAA rules) and serving a copy thereof on the other party. The hearing on the arbitration shall be held in the County of San Mateo, California, and commence and be completed no more than thirty days after the close of discovery, and the arbitrator shall render an award in writing within thirty days of the completion of the hearing, which shall contain findings of facts and conclusions of law. Any arbitrator appointed hereunder may award interim injunctive relief before the final arbitration award. Any controversy concerning whether an issue is arbitrable shall be determined by the arbitrator.
13. Consent to Federal Bankruptcy Jurisdiction. In the event that either party is not Solvent, such party agrees to and does hereby voluntarily and irrevocably submit itself to the subject matter jurisdiction, personal jurisdiction and service of process of the federal bankruptcy laws of the United States of America, as well as to the United States Bankruptcy Court of the Northern District of California.
14. Network Security and Confidentiality.
14.1. If City’s access to the data management system requires a network connection between City’s network and IHI’s network, IHI and City shall take reasonable and customary precautions to prevent unauthorized access to or use of the network connection through their respective networks. The parties agree, however, that each party is responsible for the security of its own network. Neither party shall be liable to the other for unauthorized access to the network connection, so long as the accused party shall have taken reasonable and customary precautions to prevent such unauthorized access.
14.2. Whether or not marked as such, and without regard to the media in which such records are stored, Confidential Information shall mean:
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
21 14.2.1 Any business or technical information pertaining to the parties herein or to third parties, which is furnished, disclosed or made available by one party to the other, including, without limitation, specifications, prototypes, software, marketing plans, financial data and personnel statistics; and
14.2.2 Medical records, reports and information, as well as any other non-medical records, reports or information pertaining to claimants under the Program.
14.3. Each party agrees to protect Confidential Information received herein under with the same degree of care that such party exercises with its own confidential information (but in no event less than reasonable care) and to limit access and disclosure of Confidential Information only to their employees, agents and contractors who have a “need to know” and who agree to maintain confidentiality in accordance with this section.
14.3.1 Notwithstanding the foregoing, City agrees to permit IHI to compile and disseminate, de-identified information for auditing, compliance, internal assessments, process improvement and related analytics, benchmarking purposes or forward to a data collection facility, data for Qualified Claims handled pursuant to this Agreement, provided that such facility agrees in writing to keep City’s data confidential.
14.3.2 IHI shall be entitled, without violation of this section and without prior consent of City, to retain claims administration information and to forward claims administration information to government agencies to the extent required by law for the proper performance of the services set forth herein.
14.3.3 IHI agrees that it shall respect the security and confidentiality of Nonpublic Personal Information by implementing administrative, technical and physical safeguards which protect the confidentiality of records and protect against reasonably anticipated threats or hazards to the security and unauthorized use or disclosure of such records.
14.4. The provisions of this section shall survive the expiration or termination of the Agreement.
15. General Provisions.
15.1. Notices. All notices that may be or are required to be given under this Agreement shall be sent to the respective parties at the address set forth below. Either party may change the places to which such notices are to be sent from time to time by a written notice as herein provided:
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
22 Intercare Holdings Insurance Services, Inc.
6020 West Oaks, Suite 100
Rocklin, CA 95675
Attn: Chief Executive Officer
City of South San Francisco
400 Grand Avenue
South San Francisco, CA 94080.
Attention: City Clerk
15.2. Force Majeure. Except for payment obligations hereunder, no party shall be liable for failure to perform any of its obligations under this Agreement to the extent that such breach is caused by circumstances beyond such party’s reasonable control, including, without limitation, acts of God, civil disturbances, natural disasters, or actions or decrees of governmental bodies. Upon the occurrence of any such event, the affected party immediately shall give notice to the other party and shall use reasonable commercial efforts to resume performance.
15.3. Severability. The invalidity in whole or in part of any provision hereof shall not affect the validity of any other provision. The provisions of this Agreement are severable and if any one or more such provisions shall be determined to be invalid, illegal or unenforceable, in whole or in part, the validity, legality and enforceability of any of the remaining provisions or portions thereof shall not in any way be affected or impaired thereby and shall nevertheless be binding between the parties hereto. Any such invalid, illegal or unenforceable provision or portion thereof shall be changed and interpreted so as to best accomplish the objectives of such provision or portion thereof within the limits of applicable law or applicable court decisions.
15.4. Waiver. A waiver of a breach of any term of this Agreement must be in writing and shall not be construed as a waiver of any succeeding breach of that term or as a waiver of the term itself. A party’s performance after another’s breach shall not be construed as a waiver of that breach. No failure or delay by a party to enforce or take advantage of any provision or right under this Agreement shall constitute a subsequent waiver of that provision or right, nor shall it be a waiver of any of the other terms and conditions of this Agreement.
15.5. Assignment. Neither party shall assign this Agreement or any rights hereunder, by law nor otherwise, without the other party’s prior written consent; In the case of any permitted assignment or transfer of or under this Agreement, this Agreement or relevant provisions shall be binding upon, and inure to the benefit of, the successors,
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
23 representatives, administrators and assigns of the parties hereto. All purported assignment or transfers in violation of this Section shall be null and void.
15.6. Non-Solicitation. City acknowledges and agrees that IHI personnel who perform the services are valuable asset to IHI and difficult to replace. Accordingly, City agrees that, during the term of the Agreement, and after contract termination or cancellation of the Agreement for any reason, it will not solicit, contract or hire IHI personnel or encourage them to seek employment or any other contractual arrangements with City. The parties further agree that in the event City breaches the provision of this section, City shall pay IHI liquidated damages in the amount of two times the annual compensation to be paid to such person for each breach, which is the parties’ good faith estimate of the amount of damages to IHI from such breach. This Section shall survive the termination of this Agreement. IHI agrees not to solicit business at any meeting, focus group, or interview related to this Agreement, either orally or through any written materials.
15.7. Headings. Headings used in this Agreement are for reference purposes only and in no way define, limit, construe or describe the scope or extent of such section or in any way affect this Agreement.
15.8. Records. The parties hereto shall maintain adequate records relating to the business contemplated hereunder in accordance with their respective customary practices and applicable law. Such records shall be maintained for a period of at least three years. Each party hereto, their authorized representatives and appropriate federal and regulatory agencies will have the right, at all reasonable times and to the extent permitted by law, to inspect and duplicate all such records; provided, however, that such examinations shall be carried out in a manner that reasonably protects the confidentiality of individual medical information. The obligation to maintain such records and provide such information shall not terminate upon the termination of this Agreement. IHI agrees that it will not use the records of City’s policy holders in the marketing of any form of insurance coverage without City’s prior written consent.
15.9. Governing Law and Consent to Jurisdiction. The parties hereto agree that this Agreement shall be interpreted and construed in accordance with the laws of the State of California, and that the substantive law to be applied in any arbitration shall be the substantive law of said state, each without regard to conflict of laws principles. The parties further agree to and do hereby voluntarily submit themselves to the subject matter jurisdiction, personal jurisdiction, service of process, and venue of the AAA arbitration, as well as to the Superior Court of San Mateo County for the sole purpose of compelling arbitration or enforcing any arbitration award.
15.10. Independent Contractors. The parties to this Agreement are independent contractors, and no agency, partnership, joint venture or employee-employer relationship is intended or created by this Agreement. No party has the authority to contract for or bind the others in any manner whatsoever. This Agreement confers no rights upon a party except those rights expressly granted herein.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
24 15.11. Entire Agreement. This Agreement sets forth the entire understanding and agreement of the parties and any and all previous agreements or understandings, whether oral or written, that are inconsistent with or additional to any of the various terms and conditions herein set forth are hereby canceled and rendered null and void.
No agreement or understanding to modify this Agreement shall be binding upon a party unless agreed to in writing by an officer of each party authorized to bind such party.
15.12. Counterparts. This Agreement may be executed in counterparts with the same force and effect as if each of the signatories had executed the same instrument. If the Agreement is executed in counterparts, no signatory hereto shall be bound until both parties named below have duly executed or caused to be executed a counterpart of the Agreement.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
25 IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed on the day and date first above written.
City of South San Francisco
By
Sharon Ranals
City Manager
Date
Intercare Holdings Insurance Services, Inc.
By
George McCleary
Chairman
Date
By By
City Attorney
(Approved as to Form)
Agnes Hoeberling
Chief Executive Officer
Date Date
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
26 Exhibit A – SCOPE OF WORK
Intercare Holdings Insurance (“IHI”) shall serve as the Third-Party Administrator for City’s worker’s compensation claims in accordance with California worker’s compensation laws. Consultant shall work with the City to develop claims management instructions and protocols that emphasize customer service, responsiveness, timeliness and proactive claims handling, while minimizing claims costs and reducing potential exposure to claim liabilities. In addition, IHI shall provide cost containment, managed care and other services as described in IHI’s proposal dated March 20, 2024 and attached hereto.
The following shall be accomplished prior to the effective date of July 1, 2024:
1. Claims information including data on current and prior claims shall be converted from the current administrator to the successful proposer’s electronic claims management system
2. The hiring and placement of a dedicated staff comprised of qualified and experienced personnel.
3. The logistical positioning of a service unit or office to manage and administer the City’s workers’ compensation claims, with no interruption in services to injured workers.
4. The coordination of services with related service providers, including but not limited to the City’s Excess Worker’s Compensation Insurance provider, legal counsel, and other third-party vendors.
5. Provide professional services (e.g. best practices guidance, training, project management, implementation, integration, and report development) that will ensure a successful implementation in a timely and professional manner.
6. Develop detailed client services instructions and customer service standards, that meet or exceed the standards as outlined in Addendum 3 of the City’s Request for Proposals dated February 16, 2024 and attached hereto.
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
27 Exhibit B - FEE SCHEDULE
Claims Administration Fees:
The fees and staffing model indicated below is based on a maximum caseload per adjuster of 150 Indemnity claims. One Future medical claim is equivalent to 1/2 of an indemnity claim, and one medical only claim is equivalent to 1/3 of an indemnity claim. The model assumes an average new claim volume not to exceed 100 new claims per year and the assumption of no more than 145 pending claims in an open status at the time of transfer to IHI. In the event that the frequency of new claims increases to a level that warrants the addition of staff to maintain the caseload requirements, IHI and City shall agree to evaluate the caseload for a period of at least three consecutive months before adjusting the number of staff accordingly.
Initial Term
7/1/2024-6/30/2025 $259,786.47
7/1/2025-6/30/2026 $267,580.06
7/1/2026-6/30/2027 $275,580.06
Extension Options (Renewal Terms)
7/1/2027-6/30/2028 $283.875.69
7/1/2028-6/30/2029 $292,394.96
Staffing Model
Claims Supervisor 1 Designated
Senior Claims Adjuster 1 Dedicated
Claims Assistant 1 Designated
The above fees exclude the following:
Data Conversion (Migration of historical data
including closed files).
$10,000 one-time fee
Transition and Implementation Fees Waived
Intake Services – Online Reporting – unlimited
users
No Charge
Intake using phone, fax, email, mail $25.00 per report
MMSEA Section 111 Mandatory Insurance
Reporting
Included in claim fees
RMIS/System Full Access – Up to 2 users No Charge
Account Management $5,000 per year
Subrogation 15% of gross recovery
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
28 Other Ancillary Services Billed to the Claim File as Allocated Loss Adjustment Expenses:
SIU Services
• FD1/FD2 Filing $150.00 per filing
• Fraud Package Submission and Walk Thru $500.00 per case • Background Investigation $375 per case
• Social Media Investigation $450 per case
• ISO Index Fee Pass-thru cost per index
Managed Care Services
Bill Review Services
Per bill fee* $10.00 per bill
PPO Access Fee 23% of PPO Savings
Secondary Review Specialty Bill Review (out of
network bills, bills not subject to OMFS and
complex bills over $5,000).
$20% of savings cap at $5,000 per bill.
In/Out Patient Hospitalization and ASC Bills $450 per bill Utilization Review
Level 1 – Pre-Clinical Certification Waived
• Level 2 – UR Nurse $145.00 per review
• Level 3 – Medical Director $275.00 per review
• Specialty Peer Review** $325.00 per hour
Case Management Services
Telephonic Case Management** $110.00 per hour
• Triage Services** $110.00 per hour
• Telehealth Services Subject to OMFS
• Field Case Management** $125.00 per hour
*The bill review fee is not applicable to in-network prescription bills through the Optum Network. Only out of network prescription bills will be charged the bill review fee. **Hourly rates are billed in 15-minute increments
EXHIBIT A
Workers Compensation Claims Administration Service Agreement Intercare Holdings Insurance Services, Inc.
29